Fairly new’ spinal procedure gaining fans

Over the course of 18 years, Carol Thompson’s back pain had become so intense and unrelenting that her doctor thought it was at least partly psychosomatic.

Mike DeDoncker

Over the course of 18 years, Carol Thompson’s back pain had become so intense and unrelenting that her doctor thought it was at least partly psychosomatic.

“It radiated from about 3 inches below my waist, down both legs and into my toes,” Thompson, 61, said of the pain from two small cysts that pressed on the nerves of her spinal cord. “I did almost nothing. I couldn’t cook or do the wash. I was useless around the house because I couldn’t stand up long enough to do anything.”

In layman’s terms, Thompson had a pinched nerve. In medical terms, she was experiencing spinal stenosis, a narrowing of one or more areas of the spine — usually in the lower back but it also can happen in the neck — which can put pressure on the spinal cord or spinal nerves.

The most common symptom of spinal stenosis is that, while the patient is walking or standing, pain radiates down one or both legs. Sometimes it’s numbness, more of a tingling sensation or a feeling that the legs are about to give out. Typically, the pain subsides if the patient sits down, leans forward or walks up an incline.

“As the baby boomer population is getting older, we’re seeing more and more of this,” said Dr. James Sturm, a board-certified anesthesiologist specializing in pain-related procedures at Rockford Health System. “If somebody asked me what percentage of patients 65 and above have spinal stenosis, central canal stenosis, I would say 40 (percent) to 60 percent. It’s common.”

How it all started

A heart attack in January landed Thompson in Rockford Memorial Hospital, and her problem with back pain was referred to Sturm.

“When I met him, I told Dr. Sturm my pain was 12-plus on a scale of one to 10,” Thompson said. “First, he tried epidural blocks, inserting a needle into the cysts and filling them with pain medication, but four of those didn’t help.”

Sturm recently began performing a two-year-old surgical procedure, minimally invasive lumbar decompression, usually performed when significant thickening of a ligament — called ligamentum flavum — contributes to stenosis in the central spinal canal and nonsurgical treatments haven’t provided relief. Vertos Medical, a five-year-old company based in Aliso Viejo, Calif., which produces the instruments used in the surgery, offered him training on the procedure last fall.

“Everybody has ligamentum flavum. It’s one of the ligaments that holds us all together,” Sturm said, “but in a certain patient population, they get thickening, for whatever reasons, and it occurs right at the spinous process” (a slender projection from the back of a vertebra to which muscles and ligaments are attached).

Sturm said not all spinal stenosis requires surgery, and depending on the type of spinal stenosis and the severity of the symptoms, conservative treatment may include exercise, anti-inflammatory medication, epidural injections or modifying activities so they can be done while leaning forward.

‘I was desperate’

Thompson said that when Sturm suggested the minimally invasive procedure might help, “I wasn’t apprehensive at all. I was desperate. He told me he had done 23 procedures and all but three had been successful, but none of those who didn’t get relief had gotten worse, so I was eager for the procedure.”

Thompson said she had surgery on the morning of May 21. “I went home the same day,” she said, “and it was glorious. He took out some bone, some cartilage and part of the cysts so they wouldn’t press on my spine anymore. I had immediate relief.”

The minimally invasive lumbar decompression can be done in place of an open surgery called a laminectomy, which requires a 2- to 5-inch incision, cutting of the erector spinae muscles and may include a spinal fusion. The decompression is performed through what Sturm described as two “needle stabs,” one on each side of the spine.

The needle is a trocar slightly larger around than a ball-point pen that provides access for two long-nosed tools, one to cut away small pieces of bone to allow access to the ligament and the other, called a soft-tissue sculpter, to cut small bites of the ligament away until enough space is created to allow the ligament to flatten out and stop pressing against the spinal cord.

The tools are pulled back out through the trocar after every cut so they can be cleaned before the next cut.

“The procedure is done under X-ray visualization,” Sturm said, “so the first thing we do is an epiduragram. We put X-ray dye in so the dye ... shows this bulge. You only remove the back side of the ligament itself, and as long as you stay to the back side of that dye, you should not go through the ligamentum flavum.

“You won’t even get in the epidural space, which is just one more space away from the sac that contains the spinal nerves. So you go in there, cut out part of the ligament and then you can see the dye flatten out once you get a decent portion of it removed. When a thickened ligament is really bad, it’s about a quarter of an inch thick, so what’s removed is about the size of a dime.”

Often a quick recovery

Sturm said the procedure usually takes 60 to 75 minutes, is done with local anesthesia or under monitored anesthesia care, and there is no need for sutures. He said the hospital stay is about 24 hours and the cost is covered by Medicare.

He said some patients “have wanted to go bowling the next day” but others have experienced stiffness for up to two weeks after the operation.

“This is fairly new; it’s been out a little less than two years,” Sturm said. “About 1,100 of these have been done in the United States and there have been zero cases of paralysis, there have been no infections, there have been no spinal fluid leaks, there have been no nerve injuries so far.”

Sturm said he has now done 30 of the procedures on patients ranging in age from 49 to 90 and five have been unsuccessful, meaning the patient got no relief.

“My success rate is about what the national average is — about 70 (percent) to 75 percent, but some of the patients we’ve done have been patients who didn’t have an option for anything else,” he said. “We’ve had no complications, nobody has gotten any worse, and we’ve had some who thought it was the greatest thing since sliced bread.”

What: Spinal stenosis is a narrowing of one or more areas in the spine — most often in the neck or lower back. This narrowing can put pressure on the spinal cord or spinal nerves at the level of compression.

Symptoms: Depending on which nerves are affected, spinal stenosis can cause pain or numbness in the legs, back, neck, shoulders or arms; limb weakness and incoordination; loss of sensation in the extremities; and problems with bladder or bowel function. Pain is not always present, particularly with spinal stenosis in the neck.

Causes: Many different types of problems can reduce the amount of space within the spinal canal. The most common of these problems are related to degeneration and the aging process, such as osteoarthritis, disk degeneration and thickened ligaments. Other causes include Paget’s disease, which causes the body to generate bone at a faster-than-normal rate; genetic disorders; benign or cancerous tumors; and accidents.

When to see a doctor: Call your doctor if you have numbness or weakness in your back, legs, neck or arms.

Source: mayoclinic.com

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